A nurse notices that a patient's pulse is irregular during routine assessment. What is the most appropriate next action?
Correct answer: B. Reassess the pulse and collect related findings
- A. Ignore it because the patient has no complaint
- B. Reassess the pulse and collect related findings
- C. Document a cardiac disease as the nursing diagnosis
- D. Tell the patient that a serious disorder is present
Explanation
An unexpected finding should be validated and assessed further, including rate, rhythm and related symptoms. The nurse should not dismiss the finding, make a medical diagnosis, or alarm the patient without evidence.
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About Nursing Process and Health Assessment
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
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